The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Infant Parent Mental Health Weekend: Bruce Perry

Bruce Perry came to speak to the Infant Parent Mental Health course last weekend. As usual, I was impressed by his discussion, and I agreed with him that his thinking has changed and grown more sophisticated and complex even from when I first met and was inspired by him a decade ago.

This time I was especially gripped by the notion of “dosing” the interventions that are aimed at growing the brain. I put that idea together with two other primary principles of Perry’s Neurosequential Model of Development – changing the environment to meet the developmental needs of the child, and repetitive, rhythmic patterned activity – to create the mnemonic, “RED”. Here is a summary of my thoughts after the weekend. These thoughts are directly relevant to the subjects of ADHD and Executive Function Disorder.

R: Perry frequently talks about the regulating function of repetitive rhythmic patterned behavior. This makes sense, since the body has many rhythms that are repeated over and over again mostly out of our awareness, creating micro patterns that then coordinate to create macro patterns, that help to organize and integrate our human body and mind. For example, we don’t usually pay attention to our heart rate or respiratory rate unless something is going wrong, such as the rapid heart rate associated with anxiety or panic. But our sense of well being emerges from among other things the signals these rhythms send us. An example of the coordination of these rhythms is the coordination of respiratory rate with walking. If walking at a comfortable pace, many people tend to take two strides for one inhalation and between two and three strides for one exhalation. Perry refers explicitly to walking as a regulatory activity, as well as dancing and drumming, and many other repetitive rhythmic patterned activities. In fact, music and dance often provide refined regulatory procedures that make one feel good – calm (“music soothes the savage beast”) or invigorated.

A child develops regulatory capacity through a process of mutual regulation with a caregiver (Cohn & Tronick, 1988, Tronick, 2005). This helps to explain why regulatory activities done with another person are often even more effective than done alone, for example, taking walk with another person. Even having a conversation with another person involves rich processes of turn taking that creates coordinated rhythms between the two people and also simultaneously within each individual (Beebe et al, 1992).

E: One of Perry’s key points is the importance of changing the environment to accommodate the child’s developmental needs for both regulation and for engagement.

From the point of view of regulation, that means more than adding regulatory activities to the child’s schedule. It also means evaluating the child’s capacity for processing sensory input to make sure that the noise, the visual stimulation, and the touch occurring in the child’s daily life is not overwhelming to the child. A crowded classroom or a disorganized routine can be modified to make life easier for a child with sensory sensitivities and that makes life easier for everyone in the family. Sometimes this is called a “sensory diet”.

From the point of view of engagement, this means that the child’s vulnerabilities must be engaged. As Perry says, “You can’t change any neural network unless you activate that neural network.” (Perry, 2015). Not surprisingly, children resist activities that require them to exercise functions that are hard for them, especially if their development is uneven and they do other things quite well. In that case they will tend to stick to what they do well and avoid what is hard. To help them grow, their caregivers must support them in attempting the difficult or uncomfortable task. For some children who are socially skilled but have a learning disability, this means practicing academic tasks that are difficult for them. For other children who have academic strengths but are stressed by interacting with other people, it means drawing them into social interactions, usually in play.

D: But how does one engage a child who is highly stressed by, for example, social interaction, such as very shy children or children on the autistic spectrum? Perry’s idea, which I find very useful, is that of dosing. By paying attention to the child’s cues, you can “read” the child’s intentions to “do something with you” or not. In the rather extreme case of an ASD child, you can’t just let him remain in a withdrawn position without attempting to make a connection; you often have to take the initiative yourself. I recommend small gestures that take place in short time intervals and are over quickly, and also that are of low to medium level of intensity (in noise, visual stimulation, affective tone, and arousal). After you have taken the initiative, you watch for the response. If the child seems not to respond you might try one more time. If the child pulls back further, you might wait. If the child looks a little interested, you might repeat the gesture.

The beauty of this notion of dosing is that it is coordinating intention with the child, and dosing is repetitive and has a rhythm to it. Together with the child you are creating patterns of ways of being together. So you are putting together regulation-enhancing activities with growth-stimulating activities. Another good thing about dosing is that it takes the emphasis off success or failure and places it on creating a balance. If the child indicates, “no”, then you don’t feel, “Oh, I lost him.” Instead, you think, “OK, that was a “no”; I will wait and try again. The “no” is part of what we are doing together. It is part of the back and forth.” And, of course, back and forth is a rhythm too.

How is this discussion related to ADHD and EFD? Both ADHD and EFD can be thought of as regulatory disorders (or difficulties on a dimension, if we use my preferred terminology). I will discuss this further in another blog posting.

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4 thoughts on “Infant Parent Mental Health Weekend: Bruce Perry”

Alex gets Perry in a very deep way rather than simply a formulaic approach. Rhythms are every where at every level of the system. Internal physiologic rhythms; brain rhythms and on and on. Peter Wolfe talked about the rhythm of sucking; Lashley the rhythm of skilled performance such as reaching., Beebe the rhythm of interactions. One aspect of these rhythms is that they serve as ‘carrier waves’ for non-rhythmic activities; the non-rhythmic gets ‘pasted’ or as Sander put it entrained to the rhythmic. Crucial for me is that when there is at least a messy coherence among the different rhythms there is an experience of what Harrison refers to as ‘sense of well being’. This SWB is a form of meaning made by the individua., Indeed for me the establishment of different degrees of messy coherence likely are experienced as different meanings — the highest of which is Davillier’s idea of the numinous experience. A key feature of the numinous is that it is not a removal from the world, the feeling that comes with it is deeply connected to the world of people and objects. But there are also the feelings of being out of sorts, not comfortable in one’s body, just ‘off”, ‘prettyy ok”. So while we look at the different systems of the brain, physiologic, immune and on and on and their rhythmic and arrhytmic features we must keep in mind that when working on with patients, even the littlest ones that meanings are being continuously made. Walking alone brings together multiple rhythms and a sense of connectedness to the world, “I am whole”, “I am bounded and connected”, “I feel at one with the world” (Nice!) and walking with another brrings a host of meanings, “I am liked”, “We are connected”, “I am liked”, and more. The meanings as Alex emphasizes are multiple, they are polysemic. Maybe the more meanings brought together from different levels the greater the numinous that is experienced.

Thank you, Ed, for a wonderful comment that refines and elaborates my thoughts. The “numinous” experience is a fascinating concept. I think that I will carry that idea with me on my trip to India next month.

Thank you Alex for such a useful summary and mnemonic of the Perry weekend.

I have some comments about what we mean by ‘dose.’ Perhaps Perry explained it and
tried to ‘unpack’ the term a bit. Not knowing what he said, I can think of many ways to think about the concept ‘dose,’ including ‘contact’ time’ (staying in connection for longer/shorter time periods), or ’emotional effort expended’ (how fatiguing is it for the child to try to do a certain activity or make a certain connection) and finally dose as ‘dose of anxiety to tolerate,’ since so often anxiety plays a central role in what the child is avoiding (eg., connection in shy temperament children).
Or does he perhaps mean the ‘dose’ of rhythmic activity the child requires (like a medicine) before he is able to entrain himself to the new rhythm on his own, without the external source of rhythm?
Also, is it possible to have ‘too much rhythm’ so that life becomes dull? Are ‘off beat’ activities as important to children as ‘the beat’?

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.